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Effective November 26, 2025: Clinical Policies

Date: 11/19/25

Superior HealthPlan has updated certain clinical policies to ensure medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result, the following policies are effective on November 26, 2025, at 12:00AM.

Changes in these policies reflect preauthorization requirement amendments that are less burdensome to insureds, physicians, or health care providers.

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Cranial Remolding Orthosis

(TX.CP.MP.523)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP

New Policy Overview:

  • Description
  • Policy and Criteria
  • Background
  • Appendix
  • Coding Implications
  • References

 

Electric Tumor Treating Fields (Optune)

CP.MP.145

Ambetter

Policy updates include:

  • Changed I.A.1.a.ii and b.ii. from KPS rating of ≥ 70 to ≥ 60

Enteral Nutrition and Supplies

(TX.CP.MP.550)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP

Policy updates include:

  • Updated Section III,E,1,c  to “ age one year or older” due to updated FDA clearance

 

IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures

(CP.MP.61)

Ambetter

Policy updates include:

  • General criteria (Section I) must be met in addition to place-of-service-specific criteria (Section II or III)
  • Items I.C.1 and I.C.2 were combined for simplicity and clarity in documentation expectations
  • Removed codes D9222, D9223, D9239, D9243, and D9248

To review all policies, please visit Superior’s Clinical, Payment & Pharmacy Policies webpage.

Prior to updates, Medical Clinical policies are reviewed and approved by the Utilization Management Committee.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.